Recognizing Acute Hepatitis C in Hemodialysis Patients

Abstract

Dear Sir, Hepatitis C virus (HCV) infection is common in hemodialysis patients and the relatively lower alanine aminotransferase (ALT) values in acute [1] and chronic hepatitis C infections [2, 3] of these patients make the diagnosis more difficult. Acute hepatitis C in hemodialysis patients can be treated by interferon (IFN) therapy [4], although the response rates are lower than in patients with normal renal function [5]. Lampe et al. [6] emphasized the role of recognizing acute HCV infection in hemodialysis patients by comparing the ALT level to the patient’s ALT baseline values. A 53-year-old male was under hemodialysis for 10 years due to hypertensive nephropathy. Hemodialysis was applied 3 times weekly and the serology of HCV and hepatitis B virus (HBV) and biochemistry were checked monthly. When his ALT level was measured as 29 U/l, which seemed significantly higher than his previous measurements (4, 5, 7, 4, and 6 IU/l, respectively), HCV and HBV serology was repeated. Although antiHCV remained negative and anti-HBs was positive, his ALT level was serially checked. Within 1 month, his ALT level increased to 114 U/l and anti-HCV was detected as positive. He remained symptomless. HCV ribonucleic acid (RNA) by polymerase chain reaction (PCR) was measured as 7,130 IU/l and the genotype study remained an indeterminate result. HCV RNA studies obtained 2 weeks apart gave comparable results of 5,150 and 6,120 IU/l. His ALT level increased to a maximum level of 155 U/l and then tended to decrease (Fig. 1). He was initiated with pegylated IFN alpha-2a 135 lg weekly. The study of Lemos et al. [7] emphasized the role of monitoring ALT for recognizing acute HCV infection, since the patients are almost always asymptomatic, as in our case. They observed ALT elevation in all patients and the median peak ALT was 4.79 the upper limit of normal (range: 1.1–47.4). The median interval between ALT elevation and anti-HCV seroconversion was 1 month. What is the upper limit of normal of ALT in hemodialysis patients? Espinosa et al. [1] reported the upper limit for ALT in hepatitis-free hemodialysis patients as 27 IU/l. The sensitivity of a mean ALT value C27 IU/l in the diagnosis of HCV viremia was 50% and the specificity was 100%. They reported the positive predictive value of this test in the diagnosis of hepatitis C viremia as 100% and concluded that a high ALT level can constitute an excellent tool in predicting viremia in hemodialysis patients, once other causes of liver disease have been excluded. In two studies including 19 and 32 patients with acute hepatitis C under hemodialysis, the peak median ALT levels of the patients were 345 IU/l (range: 24–1,473) [8] and 169 IU/l (range: 22–325), respectively. Another study used the definition of acute HCV infection as ‘‘a rise of twice the normal or more of serum ALT level compared to baseline in addition to a positive serum anti-HCV antibody’’ [4]. To conclude, recognizing acute HCV infection is critical, since treatment can prevent progressive liver damage by a considerable part. The ALT levels are not expected to increase by several times, so any increase compared to his/ her ‘‘normal’’ values should be considered as a warning. R. Ozaras (&) M. Yilmaz B. Mete A. Demirel Department of Infectious Diseases, Cerrahpasa Medical Faculty, University of Istanbul, Aksaray, Istanbul 34303, Turkey e-mail: rozaras@yahoo.com